the new book "we are anonymous: inside the hacker world of lulzsec, anonymous, and the global cyber insurgency" thank you for joining us here on c-span. >> thank you. >> coming up here on c-span2, let the impact that feature of american technology on the rest of the world with twitters dick costello and eric schmidt spirited discussion about the technology and privacy issues with electronic of records. and later, the center for american progress hosts a forum on the influence of corporate money on state court. >> all this week on c-span2, a look back at some of the past years luncheon speeches from the national press club. tomorrow alec baldwin talks about federal funding for arts and education and the importance of art to american culture. on wednesday u.s. airway ceo on

trends in the airline business and his efforts to merge with american airlines followed thursday by meteorologist jim kantor aide on his 25 years covering the weather. wrapping up friday with filmmaker ken burns on his documentary probation. join us all week at 6:00 eastern. >> twitter ceo dick costolo in google executive chairman eric schmidt talked earlier this month about the influence and future of american technology around the world. they were a part of this year's ashton institute summer gallup that looked at the increasing use of global video, social media, and the use of twitter during the olympics. this is just over an hour. >> thank you all. welcome. let me ask you to take your seats, if you may. i wanted thank jerry murdoch to

put this together. gina murdock, our chairs. [applause] and on behalf of our chairman and myself, welcome to our summer gallup advance. we are going to have to conversations here. i am going to moderate the second, but on the theory that you have seen enough of me, zoe baird budinger, who many of you know, will moderate. an old friend, and one of the pioneers of the digital age. let me turn it right over to zoe baird and padma warrior. >> well, thank you. some of you know me as zoe baird. [laughter]

>> i have known walter a long time. we are here today to learn about padma warrior, not me. i am really delighted to be introducing her. the chief technology and strategy officer for cisco and formerly the chief engineer. she is a real scientist, and one of the ways, one of the stories i can tell you to a confirm that took place almost 20 years ago now when katie center -- she does not know i'm going to talk about this. her wonderful husband, a former boarding school roommate of hours off to the drugstore to get a pregnancy test because it does she might be pregnant. and he dutifully went out with great enthusiasm and came back with a pregnancy test. she took the test command was positive. most of us would have started celebrating. she sent him back to the drugstore for another one because for heard nothing can be

true that less it can be replicated. [laughter] says she got her to data points and her wonderful child who is now 19. so, tell us very briefly what is cisco and what are you doing on your day job? >> well, a company that builds stitches. all that which makes the internet run. it is sort of the backbone of the internet, the physical infrastructure that you don't see behind every time you send a message or send a tweet. it is going through one of cisco routers. it is a global company with about 50, 60,000 employees, worldwide basis, including our partners. about 40 billion in revenue, and my day job is that i'd double up the technology strategy for their company. i ran engineering as well being

the chief technology officer in just about three weeks ago i moved to a new role where i now run emanate. made up of acquisitions. about apparel company. we have acquired an innovative about 150 companies. an extremely important part of cisco. >> your background includes being a major force for the development in mobile technology when you were at motorola. you now have been with a company for a number of years that has been a major force in creating the network that is the internet and, as you look out and how profound those changes have been and you think about your strategy's going forward and what you see happening in the expansion and explosion of data

and the ability to network and connect data and the explosion of social networking and the unstructured data that is coming from social networking, do you think that this is going to be as profoundly impact on all of our lives and businesses and social interactions as the internet and mobile technology has been? and if so, in what way? >> i started my career as the semiconductor industry making chips that went into building, at the time, two-way communication devices which then led to the beginnings of the. [inaudible] coming to cisco. and now motorola mobility is a part of google. it is interesting, the evolution of technology. and when the cell phone was first invented it was meant to be a business persons device. the idea was that a business person, a businessman at the

time, right, was leaving his office and feel the need to call back to the office. so that is why the cell phone was invented. really interesting. took a life of its own today. now probably about five times as many cell phones sold per every baby born every second there are about five babies born on planet earth and there are about 40 cell phones sold. it is becoming the device that we'll use and cannot live without. in the internet, of course, as we all know, played a huge role in connecting, initially connecting person to person and our actually starting to wear it is becoming a platform to connect machine to machine communication. those two worlds are merging, mobile and internet. instead of waiting to see what that will create. some interesting data points, i think, for us to keep in mind to think about this next evolution, and i think a big opportunity for us going forward. just beginning to see the use of

video. beyond conferences and beyond what we do. that has been put on youtube. estimates that by the year 2016, and for years we will see a huge amount of video traffic on the network to the tune of about 1 million manse every second. so it is a huge amount of traffic that will be video link. that, we will have to figure out at the same time, we also expect that in four years the wireless data will actually exceed wireline data. all of the data that we are putting into simi on mobile devices will far exceed that being created in wireline infrastructure, so those two things combined tell us that mobil and the combination of what mobile means in the future is going to be huge. you know, we just did a survey on fox, think about 5,000

college students and 15 countries. very interesting what that survey told us. two out of every five people in the survey say it would take a lower paying job and work for company that does not allow them to bring their own device or have access to network site twitter and facebook. the freedom of being able to connect and use social networks and use the device of their choice is more important to them than what they get paid for doing their job, which is very interesting. the other data point, one out of three of those students that -- internet is as important to them as air, water, or food. [laughter] turning over in his grave somewhere. it has become such an important part of many people's lives. and this is true in the developing world as well. the mobile device and has changed go to grad school. just when i go back to indiana

and as the the cellphone everywhere. very remote parts of rural india. go to visit families, everyone has a cell phone and use it in very different ways and how we use it. having a huge impact. i think where we go in the next decade will, i think, also began to see what people usually are doing, machine to machine communication. people communicating. we will see lots of low band with data constantly being sent to the network. and so you see this a different type of data structure the you will have to deal with. what will be media rich, those types of data and the other will be small groups of data that are continuously streams. we are beginning to see that already. being made better by having sensors that monitored the great. and so you can think of a set of

protocols. as electrons moving typey networks. >> you think will whether those can be integrated into enabling people to use the fact that the, you know, everybody can walk around with one of these to create new kinds of jobs that people are doing today? do you think about how to enable that, not just that someone must be able to bring their iphone to worked or their devices to work but rather that all of a sudden they can do new things to create ways of making a living. >> absolutely. cisco trained a lot of what we call that working. 10,000 academies where we bring in people and train people. we want people to be connected.

the same time, a deeper level. you can think about job creation. the connective become a lot of world workman activity is an issue and broadbent penetration is an issue. raised tonight policies driven. chance to the digital world. what does that mean? a recent article i was reading in the new york times that talked about how it is now actually -- we become habitual to using technologies in different ways. it will be an interesting aspect.

twenty-one days for inaction to become a habit. sixty-six days for something to become a good habit. in other words, if you want to stop climbing the stairs every day after lunch you have to do that for 66 days before you can stop thinking about it as a habit. think about how you use the device constantly. a good habit or a bad habit. it is the way people's brains function which in itself creates new sources of innovation which would drive jobs to be different, but there will be opportunity to drive different kinds of industries. in the rallying we see this already with things like interest. it is a way for digital clipboard and you find a website or a picture. in a, it reminds me of when i was a kid. i used to cut out pictures from magazines and literally used pans to put it on a bulletin board. now i do it digitally.

new opportunity for us to share and work in a very different way going forward. gaming is another thing. very interesting data point. again. i was reading. today 7 billion hours of gaming every week that happens on line. video games online gaming. some people think that was insane. 7 billion. every week. at the same time the university of california and san francisco had done some research. actually gaming can delay the onset of dementia and other things because it really improves creativity and been very focused. extern the focused people. so at the very early phases of figuring what the future will be

like. that is where we are really excited. >> when you think about being your own trajectory, one of five women in a class of 250 at the very prestigious institute in new delhi and you looked at where you are now and the women around you, how do you feel that things a changed for women in engineering and sciences? i knowou spent a lot of time mentoring women and encouraging them to develop in the fields. >> yes, so when i went to college i did my understanding at the indian institute of technology. the very hard core engineering schools.

only five women in my class. 250. and, you know, i went to college when i was 17. thinking i was on the plan and everything. quickly realizing that really smart people, people that are much smarter than me. very intimidating. what helped me get through my engineering curriculum was the fact that there were four other women that felt the same way that i did. they really stuck together and became a community, so to speak, that helped each other. at the debt experience stayed with me throughout my whole life. i feel it very important because there are very few women in technology and in science. starting companies, connect them it is an informal way to share

experiences. how does it change? think it has just the notion you can surely recognize and be a leader. excepted more now than it was when i started working almost 20 years ago. when i started working and i started my career in the semiconductor industry which was a very hard core technical industry, you know, we were told to dress a certain way, talk a certain way, if you had a soft voice you would stand up when he spoke to people would see you. there were just 78 years that would be imposed of you as a woman in the industry, and i think these days when that enter the work force can feel like they can be themselves and that is what i tell women that i mentor. the most important thing is to be who you are. a few of jewelry where jewelry. a few of shoes wear fancy shoes. don't try to be someone you are not.

i don't think their is a particular way that you have to be or force herself to be to be recognized. i think that part is changed. >> twenty years ago i thought that one of america's great global competitive edges would be our ability to take advantage of the 2 percent of our population that was women. we would be able to draw on that talent in a way that other countries would not. do you think that is true? i mean, is that a place where america has a competitive edge or do you think that is pretty much the same within other countries with which we compete? >> i think we do have a competitive edge. women by and large -- in the whole reason i came to the u.s., for that reason, go to graduate school, i tell women and others who are entering my story of how

i came to the united states with a hundred dollars and a one-way ticket. i felt like i could be successful here. my original plan when i came was to finish my ph.d., go back and teach in india. i started working and felt like i could have a great career, great family. and i think that is in general true. at think we do provide an environment where people, both men and women, can be competitive and can't really rely on their contributions to become successful. having said that, i think -- and i just participated in a research that we did, a research university report that we did for the congress. we were looking at university research and talking about american university research weakening or it was the bearer to wear western years ago. the university administration and research program, participation of companies or

contribution by the federal state government. a combination of factors. i do feel concerned that we do need to do more to maintain our age and higher research in universities because that, i think, you know, is still where we differentiate from other countries. getting talent from the rest of the world. so i think it is important to maintain our competitiveness in higher -- higher education and i would say higher levels of research within universities. >> in addition to taking advantage of the talented women in this country and investing more in research, what else do you see as potentially competitive edge for this country? compete with india and china and others. >> i think entrepreneurship and innovation is truly an edge. you know, even within the u.s., the notion of silicon valley is difficult to replicate. you know, there have been lots of case studies done on, can we

do that? we are seeing more and more pockets of innovation like the rally come up in new york city and other parts of the country which is extremely important. amazons state department sponsored a trip to russia, and russia is now thinking about, you know, creating a concentrated effort where they can encourage entrepreneurs to start companies. i think this is a u.s. to release of leading the world, and we need to maintain that magic formula of creating great risk taking with great ideas that young people can come up with ideas and create companies that go into big companies. i think that is what keeps us really apart from the rest of the world. we need to do everything that we can to put that back. that is a combination of various things. >> year -- [laughter] >> a hard question.

here's our question. president obama was elected, he was very interested in your being his chief technology officer and for family reasons that is not the direction you went. had you taken the job or if you took it now what would your priorities b? >> you know, i think their is a lot that we can do. first and foremost, investing in big problems that we need to solve. alternative energy or synthetic materials, new materials, there is a law which can do in understanding the research that the universities, the material scientists. may be unbiased. going back to visit the creating new kinds of things is as important as the web and may be counter for me saying this because i work this is done now, but i think it is as important to look at innovations that we

can drive as well as digital innovations. if we look at areas like energy, new materials, those types of things, the government can actually really sponsor large-scale research projects working with research universities. then companies obviously can benefit from that and we can create new types of industries coming out of that. that would be something that i feel, whoever the president is has to have a mandate from a technology point of view. >> we won't get into that question of whether you can have it all. we just can't talk to that year. but an analogous question is how is it that you manage to keep fresh and, indeed, to succeed in it all? family. you have a wonderful husband, a child. you have an extraordinary career. you are out hiking this morning. the new york times story on you recently said that every saturday morning you take a digital detox.

tell us what that is. is that part of what enables you to have it all? >> so, yes. every saturday morning i made a rule about a year-and-a-half ago. attica new job about three years ago to run all of our enterprise business. i was working. it was really getting to me. but a year-and-a-half ago i made a rule that on saturday mornings it's my time, and i like poetry. i painted. this morning we went hiking. i want to do something that keeps me always. i really am disciplined about doing that. there are occasions where we have to travel. but by and large i feel it is really important. in this article i talk about it. i find that sometimes things happen constantly.

just like when you exercise physically, you feel more energy, more energetic versus feeling more tired. when i medicate and when i paint or if i'm ready i can think more clearly. when i'm sending will would have been a nasty e-mail and much more called. so i think that this is a disciplined way for me to think clearly. >> a great privilege for all of us to have you here. thank you, and we look forward to you. [applause] >> thank you. thank you, sally -- zoe baird. while they are getting seated, let me say that this evening we are honoring the three of them for their service to technologies and society, but

the reason that my old hero, eric schmidt, and my new hero, dick costolo, yes, that's right. sorry, my long time. young and longtime. not only to talk as technologists, but something that we have been talking about a lot this summer which is the effect of technology on democracy and on world affairs. the best book to be written next year will be written by eric about the effect technology and the arabs spring, but also the democracy movement and in this country. obviously tick is looking about how it changes our society, democracy, and for that matter the world. i will start with a tail that was told a dinner and nine or two ago, the head of u.s. aid, the agency for the national

development, and he said that in their tweeting the location of the demonstrations. something she had learned at a class, the american university in cairo called social media under authoritarian regimes. then, of course, one of eric's employees at google really did help start the revolution. how much do you think the revolutions of the arab spring were affected by technology? >> every revolutionary uses the tools and technology available to them. i went to libya right after khaddafi was killed. what was interesting in talking to people was that they had tried to overthrow this evil dictator multiple times, and many had died from it. and the dictators had learned

that you have to a sensor the media, radio, telephone lines. they failed to sense of the internet because there were too old. by the way, the syrian dictator has learned that lesson. so i believe as much as we would all love to take credit for this we should give the real credit to the courageous people who risk their lives. and we were simply a tool for them to start something. i should also say that it is much easier thanks to twitter, facebook, and youtube, to start a revolution. it is not any easier to finish it. and so we are a small part, i think, in a much larger thing. the saying is that you use twitter to get people out on the streets, facebook to organize them, and youtube to record the results. we will take that. >> made a very good point, which

is it is hard in the revolution. i remember in 1989i covered eastern europe, and there were using faxes and satellite tv. but they had organized. and in the shipyard, and prague there was hobbled. they created revolutions that had leaders. and the revolutions succeeded you knew who was going to be in charge. ..

ignoring the question of social value, and what is interesting that the brotherhood is that they don't actually tell you what they're going to do. they're very careful. just like all politicians -- to not actually say what the tradeoffs they're going to make are. >> how do you see the resolution from the advantage of twitter? did you think you would you be a force like that? >> not at all. i'd start off by saying that if he was on his game he would have had people attending social media for authoritarian regimes, but, no. in fact, during the events in iran, a couple years earlier, we were getting ready to plan the maintenance -- at a time when twitter was still in infancy and we were getting ready to do planned maintenance, and the state department contacted us about all the activity going on in iran, and asked if he could

postpone the planed maintenance. that was an eye-opened for everyone in the company. we didn't -- we sort of found out about the -- what was going in tunisia via e-mail from one of our users in tunisia who goes by the i.d., @slim 4004. his twitterty. now the sponsor minister of youth and sports in the tutu nyeshiaan government. so it's kind of washes over you. it's nothing we anticipated or planned for or even do anything to promote. it's all been us react to how people have used it -- >> have you had difficult decisions? i now you say being called by the state department. i assume it was partly eric and

allen and others. what tough decisions have how had to make now that twitter has become such a political tool in this world? >> there have been a bunch. we're blocked in iran and china so you have to -- as eric is well official with you have to make lots of decisions about what you will and won't do in those kinds of places. we remain blocked in iran and china. there are people in china who use twitter, but -- >> what will you do in china to push back? >> we're not going to go there in the way we would have to go into that country right now, which is to provide access to governor censors. so we're not going to do that. and i imagine with the new government coming in, it will be in fact much worse for a period of time. it will be worse for the companies already there that

have twitter-like clones they've built. we were down in pakistan for a couple days, and were asked to remove a certain number of tweets. otherwise the service wouldn't be brought back up, and we didn't remove those, but ultimately they brought us back up anyway. there are -- in turkey, it is considered a -- we're told be have to delet certain things or we're going to take it down, so you have to balance letting people have access and make sure you're not censoring things. >> eric walk us through the

tough decisions you had to make on china and other places. >> dick described it perfectly. you have something that the citizens of x country want. and the government of x country fundamentally does not want it on your terms, and it's a power play. so, in turkey, for example, we were blocked for nine month on youtube because of a single video, which was immediately taken down. it may have been that the generals were also a little concerned about the other videos that were on youtube but no one would tell us that. they've since invoked, by the way, a censorship law which applies to every internet connection in turkey, which allows them to arbitrarily censor at any ip level. >> in the youtube part of your business, do you cry to six-kim vent that. >> the more we circumvent, mow more likely employees end up in

jail, and turkish jail is not that good the broadband isn't very fast. so it's a real fine line. our employees face a risk of incarceration, and are often hauled in and threatened. we've not had anything worse than that and we try to be careful. china is a long story which i will summarize, we tried and it didn't work. >> but you pulled out a bit from china, right? >> a bit. come on, basically we -- and i in particular -- felt it was better to engage rather than to be estranged. that's a proper philosophy. you need to give it a try. and our theory was that we would create something that was so incredibly val tubal the citizens of china, because in our arrogant view we provide great value -- that the government will be forced to over time open this up, but the censorship at some basic level is not going to be okay. we did that for five years. the censorship got worse, not

better and after the chinese government or its proxies attacked us for months and stole a butch of stuff and we have since corrected that. be welcomized that. and after they engaged in a very long and severe campaign, monitoring the g mails of human rights activist, we said, enough is enough. you gave us a speech, one country, two systems, we leak the hong kong system better we're moving to hopping dong. they didn't like that. and there's a fire wall -- known as the great fire wall -- and it's a censorship box, a proxy fire wall which basically, when the information goes through, it automatically censors. so we solved this probably be making the chinese government do this nasty censorship. what are the kind things censor ed in china? interesting question. it's illegal for me to tell you but since i'm knock going there anytime soon, i'll give you a summary.

the mayor's son rated. a phone call comes from the police which says delete that reference. it's not political thought too much. it's not the kind of thing wes mostly see. it's things which are personally embarrassing to the leadership and especially the senior leadership. people i don't think maybe understand the magnitude how hard the government of china will come down on even simple sarcasm. this woman in china, who was accessing twitter basically via a virtual network in korea, retweeted a sarcastic joke that someone made about a local chinese official. she just hit the retweet button, and she was sent to a labor camp for a year. >> the guy in pakistan who tweeted a comment about -- basically mohammad, who then immediately deleted, fled to, i think, indonesia, foolishly

announced his location, was arrested and sent to saudi ayoob and hasn't been heard from since. >> yes. there is example after example of a -- what you would think of here as the tiniest remark that is on that list of what you can always consider to be cruel punishment. >> is it getting better or worse in china? >> um, well, the send soreship in aggregate is getting worse. it's reasonable to also believe that they're losing. and the reason is that the rate of adoption of the chinese social media, they can't stop that. and so even if twitter was blocked, which obviously is in my view a terrible thing and bad for everybody -- and the way they block it is they make it impossible to get there they just say no and they don't care because they're not elected. remember. wabo was the way in which the

chinese train incident were the train was shoddy and the government lied about it. even in a dictatorship, the government has an ego and cares about being embarrassed. so even there, twitter and its inspired followers-changed the government. it's really remarkable. >> do you think that the advent of information technology and the free flow that it enables, inevitably pushes towards individual empowerment and democracy? >> it certainly pushes from individual empowerment because you're empowering individuals will off these devices. the numbers are staggering, from roughly two billion internet connect devices to -- by smartphones, over the next three or four years, six or seven billions and it's reasonable to expect in the next ten years all

but the bottom billion will have reasonably sophisticated smartphone, with becausersed and so forth, and reasonable data connection. whether that produces democracy is, i think, a western view. i don't think you can prove it one way or the other. >> a natural connection between individual empowerment and the desire to choose your own leaders? >> that's a western view. a different view is you could say it produces chaos that has to be appropriate -- >> that's when -- the western view, too. >> it does not necessarily follow that this extraordinary empowerment, which is so good and we're so excited about, that i think dick exemplifies -- doesn't necessarily follow it leads to free elections and multiple parties and the parliamentary situation. those came out of much more complicated societies. my own view, the future is going to be much more unpredictable and much more bizarre than we

think. the reason i say that is that 20 years ago, i was sitting in my office at sun, and i thought i understood everything bat what was going on and there was nothing new. then one day mark invented the web browser. and i discovered there were all these voices i had not heard before. so we're got to good through the same fem na on a global scale because of cell phones and twitter. we haven't heard from them yet. it's presumptive to assume awant a particular demography. so, from a book perspective, my conclusion -- me summary i would say is that the rate at which things are happening is going accelerate. in america we assume that everything is sort of static and rate of change is slowing down and everything is getting boring. this is false. the platform 'that 'padma talked

about, twitter and facebook in particular, many such platforms of massive network stale, that will empower whole new forms of social activity, literally at a global scale, modeling interpersonal behavior. >> do you see, dick, the people using twitter in different countries and different cultures, do they use it differently and do you learn from that? >> sure. the short answer is, yes, they do. for example, just pick one, in japan, the japanese use is a lot more as an alternative form of communication, say to text messages or a phone call than as opposed to a way to keep up with the news or follow your interests or pay attention to what your heroes are saying. it may be the case that some of that is in reaction to the

events of fukushima and the earthquake and the ensuing tsunami but it's absolutely the case theyite much more as an alternative form of personal communication than people in the rest of the world in brazil, it is almost exclusively indexed to following celebrities and celebrity as opposed to keeping up with the news or following your interests or keeping up with events. so it is absolutely the case that people around the world use it much, muff differently. >> what did you learn from the olympics you have? >> the olympic tie has been fantastic. one of the fascinating things about the olympics, i think, has been that this i think it will be really interesting for media -- the people in the media industry to understand this change that we're going through from a filtered outside-in view

of the event, where there's a broadcaster and they interview michael phelps before or after the x-rays you get -- after the race and you get this linear progression delivered to you in a certain way. now, before, during, and after the event, you've got this unfiltered inside-out view of the event from the participants and people who are at the event, even some of the par tis pants taking a photo of the guy three lanes over and tweeting it. >> i loved at the opening ceremonies, every athlete marching in seemed to be taking pictures and tweeting it. >> brought a tear to my eye. [laughter] >> i think that 'will fundamentally change the way media starts to think about how they deliver events events to us it will no longer -- it will start to get boring if their view of it is the single

filtered outside-in view while there's a dramatic multiperspective inside-out view. >> if we're feeling sorry for the nbc folks who spent all this money to do something which is time-delayed, and they've insert ads in lots of feature stories and wonderful narratives how the athletes and their personal stories and so forth. there's an alternative narrative, which is, watch the olympics via twitter. boom, boom, boom. at it just a different choice. >> on that point, leaving aside hash tag nbc fail, how do you think nbc now feels about your almost trumping them in some ways? >> well, we have a partnership with nbc that we're working on the olympics with. so, i make no claims about how they decide to broadcast what they broadcast. the partnership has been

fantastic for us. the partnership with the ioc has been fantastic for us. the london organizing committee has got cameras at the event -- sorry -- inside the event just tweeting -- taking pictures and tweeting them. there's a pool camera at the bottom of the pool that is 2008 photo0s the swimmers as they dive into the pool. so you're just getting this fascinating inside-out perspective. i think that enhances what nbc is doing, and then they've got the broadcast aspect of what they're doing. to think about what's going on in real time. >> eric, let me switch and ask a question, which was, if -- ask zoe a question, if you were chief technology officer, what should america be doing now,

government, to make sure we stay competitive? >> i'm a member of a science advisory for the president, and one of the things to know is that america's technological leadership came with an awful lot of help from the government. it started after world war ii and the was a gentleman named van bush who forsaw building the underlying science infrastructure, and that underlying science infrastructure is what created everything that dick and i and padma and so forth, represent. literally in the are 40s and are 50s they laid the ground work for the physics physics ani conductor revolution, all of that. so for people to say it's the private sector, they don't understand how it works. the question is not, does it have the role but what is the right role. it's clear the america's

leadership is a key part of that. 18 of the top 20 leading universities in the u.s., champion has zero. sorry to go back to that subject. the fact of the matter is, there's something about the american educational system at the higher level, college and beyond, which produces people which can create things of great value for the world. we need to invest in that. so, let's start with investing nor education. at every level, and that doesn't mean giving higher races for union members. right? it means creating choices. by measurement systems, getting -- saying we're going to go back to producing students as good as the koreans are producing, the japanese are producing. what about the iat in india? phenomenal universities. if you're not willing to take that as bias, it's hard to have a conversation. to me this is such an obvious political point. i don't understand why there's a

debate over it. i think it's because some of our political leadership operate on the assumption that the facts are optional. [laughter] >> the fact is, the fact is that we have a demographic challenge involving aging, globalization challenge involving global competition, and an automation challenge because jobs are being replaced by machines. the old jobs are not coming back. the new jobs are correlated with high educational achievement and things which america is very good at. so figure out a way to fund more of that to the maximum capacity of american humanity is what we should be doing. [applause] >> you know, just briefly, i'll say that you get an acute sense for how important this is.

we were recruiting this young woman who graduated with a computer science degree from princeton, and we interviewed her and decide we wanted to hire her and he was choosing between twitter and google and facebook. she went to google. i'll tell you how the story ended. i said, let me get on the phone with her because it maybe if the ceo calls her, -- this is making me look bad now telling you she went to google -- so i got on the phone with her and she called me mr. costolo, can which was funny because nobody at work addresses me this way. and i had a half hour conversation with her which i thought went well, and she said, want it to thank you for taking the time out. now you're extremely busy and it's been incredible for me to speak the last few days with executives from twitter and facebook and google and i had this realization that it's that

hard to find a woman in engineer that interviewed that well with us. in america it's a real problem. >> it's important to note there are shortages of advanced manufacturing talent in the midwest because what happens is that the new machines are sufficiently complicated to operate that you need people with college engineering degrees to operate them. we're not producing enough of them. in this country. and because we don't allow foreigners to come and work here because we don't want them to come and pay taxes and create new companies and make lots more money for everybody. i'm sorry. i'll stop. >> i would like to get to the stupidest policy of the government. >> here's something i don't understand. the technology and digital revolution has totally transformed most entries. i happened to come up in the

magazine and journalism industry. talk about disruption. and yet the one place that hasn't truly been disrupted is the education industry. the textbooks -- most people are still carrying textbooks. and they're coming along, yet in almost every place you good to there's a teacher standing in front of a blackboard, whether it's a college or -- >> if you think about it for a while, what's included in the educational system below college is run for the benefits of the adults and not the children. and there are many possible solutions and we should try them and all measure the outcomes. >> that's -- >> we teach statistics in high school. we should apply them. [applause] >> give me an example of how

technology could disrupt the classroom. >> i'm now on the board of the kahn academy. john and -- created the opportunity of a lifetime, roughly speaking, eight to ten minute videos, a gifted teacher and they're on youtube, and i have the three million videos, big numbers. so, they had the brilliant idea of saying, what happens if you inverse the classroom, and you go to the point where, when the student goes home they watch the videos rather than doing homework and they do the homework in the class in a self-paced way and have interesting and powerful thoughts for the gamefies the process, and the earlier results indicate a materially significant improvement in advancement in middle and high school classes. one that is statistically valid in a normal business, if

somebody showed you that you would immediately adopt it. i can assure you it will take is 30 years to do it in america. nevertheless, there is real proof that new technologies to education can work, and the rough -- the way to understand it is that if you're building knowledge and you get stuck in a classroom, you lose the whole year because everyone moves forward and you don't. whereas if you can come up with technology that can help you learn aggressively and in an interesting way, in a way that's largely self-taught, and it's fun and interesting, you're going to excel, and there are plenty of examples of people who have been marginal lies who -- marginalized who had trouble with long division. >> tell me about twitter in education. >> i think in the broader social context, we talked about for years and years the fact that

technology removes the barriers of time and distance between people's communication, it's almost trite to talk about it. it's now so collapsed with these real-time communication platforms and so eliminated the barrier of time and distance, that all these other artificial barriers are being removed. like the barriers of socioeconomic status to communication, the barriers of status to communication. so, that will afford all sorts of opportunities for -- in government and education, just to continue talking about education. solomon rushdie uses twitter all the time, and in fact he gets in these remarkable conversations with other literary figures on twitter about fiction, and if you follow all of them, you will get a remarkable education and how to craft a character and how they think about character and

how they think about each other's works and why they prefer this work by this south african writer to this work by this other writer. it's remarkable and all free. so you would think if you were teaching a creative writing course, one thing you would do is gather a list of these remarkable authors who are giving you this advice for free and bring that into the classroom. >> could that be the next phase of twitterer you try to facilitate that consciously? >> i think what we'll try to do is facilitate the ability for others to do it. for others to curate these collection office confidences. we don't do a good job of surfacing those now. there's so many remarkable conversations that take place on the platform, and i'll even find out about them six months after they happened, or sarah, one of my favorite conversation of all-time is almost a year ago, sarah silverman tweeted, whenever your family is driving

you crazy, just pretend you're in a woody allen movie. [laughter] >> the response, from mia pharaoh, which was even better, tried that, didn't work. [laughter] >> i know it's fantastic. she is my hero for saying that. i didn't know about that until four months after it happened. and that should be front and center. weed in to provide the ability for people to curate. >> what is the next phase for twitter? >> that kind of thing, providing ability to curate events and conversations about the events and accounts people should associate with these events and then broader topics from there more generalized topics without beginning and ended. >> eric, do you worry at times that social media twitter, whatever it may be, can be either polarizing to our duff course or alienating in some

ways? no. >> what is causing the polarization or the discourse. >> we have had that for hundreds of years. go back to the brad sheets in 1890 in britain. if you want to -- all you're seeing is the old behavior using new forms and we're finding out how people are really made. i think it's beautiful. think about off -- all of these voice. sarah veilman story. you would never have heard it. now you can hear it with a thousand more like it. >> think one of the challenges we have, we allow studentsen twitter, like the fellow who tweets under the name slim 404, which hopefully isn't his actual name. i think one of the challenges for us is that there are two sides to that coin of anonymity. ...

>> it should be relatively easy

for the systems to figure out what you like and organize them in such a way that you see the age and politically appropriate stuff that you want. and anonymity has its negatives. there are places where, for example, anonymity is really a problem. it can be incredibly important. if you take a look at mexico, because the government -- the local government has been bought, you cannot use a helpline because people believe that the helpline will bust. you need to have real anonymity. absolute anonymity to get people to tell you what they know because they are afraid of deathly retribution. it is a fine line. we will figure out as a society where real anonymity is appropriate and word is a terrible idea. >> and in google plus, you are feeling your way there. what have you found?

>> we require a real names policy and we felt that in feeding these networks and feeding of a social network is very important, is it appropriate, isn't it a fantastic design, whether by example or accident -- an example of how to do it right. and we have now liberalize the for the same reasons that we have examples. it is much easier to liberalize and to restrict it once. >> do you think that anonymity leads to a course of dialogue? >> there is lots of evidence all minded people say things that they shouldn't and that they would not face-to-face. this has been known ever since e-mail. it is the old thing a look at the e-mail and think before you press time. [laughter] just think. if you have to think, then you probably should not press send.

>> that's been known for a long time. now you have a generation of people who haven't understood that there is no delete button and so if you look at this, and i interrupted you what the example of twitter and the fellow who made a sarcastic tweet about mohammed. and now, five seconds is long enough to your on death row in saudi arabia. this is the generation that is now going to be defined by what they tweet for facebook and all the future society. that stuff is not going away. >> let me end with this question to both of you. the last tworevolutions since the 20 years in which the internet was web dominated, the advent of social networks and mobile, those in some ways come together. what do you see as the next big

thing that is going to happen in the digital realm? >> i think it will be something that emerges out of the fact that mobile computing is very close to being ubiquitous. that we probably can't conceive of yet. it still changes the way people interact with their world. the fact that they have an always on device with them. something that is sensitive to all this information going into right now, etc., that will foster some sort of innovation or revolution that we can conceive of the. >> you think that there will be natural interfaces. almost machine intelligence and machine learning? >> we were talking about this earlier. at some point, probably sooner than we'd like.

you already see things with technology. this was a test to boil it down, a test behind closed partitions, you can ask a series of questions and not able to determine whether it is a human or machine answering those questions. you know, i am already amazed by things that theory does. it is a hot skip and a jump with the machine learning that some of our great scientists are doing passing the test sooner than anyone would like we met a like to think this as a supercomputer. >> so what i want you to think about is think than in five years or 10 years, this is a 40 or 50-dollar device. as technology cheapens and volume increases.

we have that many platforms, what will i be like. well, these are very personal devices. every one of you has them on you. the proposed you've never take it from someone, you never look at it without their permission. it's a highly personal device already. as the technology gets better, and again i should say that this is all what your permission, 500 times, these devices can help you decide where you should go, who you should meet, it will alert you to things going on around her. it is the intersection of mobile and local commerce, essentially, on the single platform. it was not possible and for the last two years. it was a whole new generation of of google's application, facebook, etc.

there are some who have grown up only with this model, backed up by extraordinary development developments in machine learning. computers are very good with needle in haystack problems and they have very good memory. one way to answer your question is to imagine the separation of man and machine. do we do what we're really got, which is being human, and these things do the thing that we are not met. we remember everything, we make very deep suggestions and they follow serendipity to keep you entertained. >> thank you all very much. you can see why we are honoring them tonight. >> thank you. those of you who are kind enough to be part of our event tonight, let's proceed or we will have cocktails and honor are three

people. jerry and gina murdoch, thank you very much. >> all this week on c-span2, a look back at the u.s. military for a past q&a programs. tomorrow we talked to codirector rachel liebert and jerry and singer. it chronicles the retired surgeon's efforts on the behalf of marines and their families, exposed to toxic drinking water at a marine camp in north carolina. join us at 7:00 a.m. eastern here on c-span2. >> on "washington journal" tomorrow morning, associate professor will discuss early voting in this year's election. a visiting scholar at the american enterprise institute will take your questions about his plan to privatize the postal service. and we will be joined by james trout, a member of the council

on foreign relations with a look at the so-called obama doctrine. the administration's position on multilateral institutions such as the united nations. "washington journal" is live on c-span everyday at 7:00 a.m. eastern. >> smartphones may soon be on the frontlines of patient generated health information. according to a panel discussion between the health and human services department and the health care industry. they discussed new technology being tested by patients and doctors as a way to monitor health and give patients more involved in their own health care. they also talked about security and privacy concerns with electronic health records. this is about an hour and 45 minutes. >> my name is ed howard, i am with the alliance for health reform. and on behalf of our board of directors and chairman, i want to welcome you at all patient generated health information. its potential for making our health system function more

efficiently and in a more consumer friendly way. we will be hearing about a bunch of them i guess you would call it weighs technology, devices and processes that can transmit your weight or glucose level to your electronic health record, where your physician can use it to monitor your condition. and we will hear about some of the potential advantages of the technology. challenges that those initiatives are encountering and what can be done. we have to partners today in sponsoring this briefing. one is the robert wood johnson foundation technology and information, which has been helping americans enjoy healthier lives and get the care that they need for 40 years. some i have a little button that i meant to her. thank you very much to brian quinn and robert wood johnson foundation technology and

information. you will hear from robert wood johnson foundation technology and information in the moment. the other is that by policy partisan center. two senate majority leaders from each party, former senate majority leaders, is the only dc think tank that promotes bipartisanship and has health care is one of its main focus areas. we are very pleased to have monitoring this discussion, janet marchibroda, who cochairs the technology initiative. i would like to turn to her at this point. >> thank you. it is a great pleasure to be here today and to be talking about something that is very important to us. the health i.t. initiatives at the bipartisan policy center. as a threat to mention, we were established in 2007 by senate

majority leaders and focus on a broad range of issues. one being health care. we are particularly interested in the discussion today because we are talking about how one could more effectively engage consumers and patients and their health and health care, using electronic tools. something that we focus a lot on in a recently released report, the bipartisan policy center task force on delivery system or form and i.t. we are experiencing a number of pressures in our health care system today between rising health care costs, uneven quality, roving coverage and clearly, when you look at all of the rapidly emerging initiatives moving across the country. sponsored by the federal government, states or even a number of private sector plans and providers, all of them have a key goal of activating and engaging at a much higher level,

consumers and patients and their health care. we have a tremendous opportunity to leverage electronic tools, mobile technologies, online tools to make that happen. in fact, what we're going to talk about today, a number of consumers, as we have found them and there has been a great deal of research in this area, would really like to use a smart phone or pda to monitor their health because they were able to access their medical records. and also, not only down load information the user could help reduce. some research was used in the case, an article published over the last couple of years, that while 64% of physicians have never used a patient's electronic health records can only 2% are willing to try it. we are seeing a lot of interest in this area. in fact, stage two of meaningful

use. there is a proposed rule that actually has a number of key requirements that are proposed around further engaging patients and their health and health care decisions. electronic health tools, like the ones we will talk about today. there are some key areas that we want to explore to make exciting things that we are hearing about in this panel today, move forward in a more accelerated pace. the first is, and i'm looking forward to hearing some of the presentations around how between policy and market actions clinicians, this is a new thing for them. how we can continue to support and educate and help them transition to these new ways of providing care and interacting

with patients. i know devon to my left, and also joy, they are going to talk a privacy issue and policy. maybe a little bit about security. one of the key things we are hearing is about the need to align incentives further. to make sure that this happens, and of course, continuing to build awareness among consumers and ensuring that nobody -- no one gets left behind due to access to some of these technologies and the like. the one and i can put it on a slide for folks -- there are some technical issues that would also need to be figured out. i know we have a policy audience, something called data provenance. what exactly is that?

sort of figuring out if i have different sets of data, where did it it come from? so i can better understand of the sources of particular data sets to help me deliver better care. with that, those are my comments and i look forward to hearing the discussions of the panel. >> that is terrific and thank you very much. before we introduce the panel, let me just go through the logistical checklist, if i can. there will be a webcast and a podcast available sometime tomorrow on js.org to whom we are very grateful for providing that service. ksf.org. you can also viewed on our website at allhealth.org. he.

>> leader honestly, if you are watching us on c-span right now, and you have access to a computer, you can go to our website. allhealth.org, and if you punch of this briefing available on the homepage, you can follow along with the powerpoint slide presentations for the speakers will be using. there are packets that you can use to address questions two and a blue evaluation form, which we hope you will fill up the out before release of the we can improve these briefings as we go along. one other announcement, this, and pardon my terminology if i don't get it right, but this briefing is being tweeted with a

hash tag. and you can re-tweet if that is something that you do. we have a full panel assembled. i would like to thank robert wood johnson foundation technology and information for helping to do that with his colleagues. fittingly, i turn first to stephen downs. he is the chief technology and information officer making sure that the foundation's technology strategy is in line with the rest of its program activity. he is also the codeveloper of project helped design. which is an integral part of today's conversation. >> thank you very much, good afternoon. let's start with the key developments you, which is that health is becoming digitized. notice that as an health and not

health care. we all understand health care, the care that we get in the hospital and doctors doctor's offices and pharmacies, that's all becoming digitized as well. increasing adoption of electronic health records. we think of health differently. it is what happens when you are not at those places. it is your day-to-day experience in it is increasingly understood as being a function of the environment in which you live, work, learn and play, and the decisions that you make and the behaviors that you take on in the context of that environment. increasingly we now have technology that can really open a window into the day-to-day experience that drives your health. there are two key drivers. to technological two technological drivers. the first is the smart phone. the way i'm going to illustrate this is an example of a company called ginger io. the laws of your calls and text,

the accelerometer data, which shows how you're moving and gps data, which shows how you have been places. it is a digital elemental signature value. you may be a having a behavioral a behavioral signature and they can look at deviations from that and say perhaps if you're prone to depression, you might be sliding back into a depressive episode. despite analyzing the status. you have to do nothing. i really want to stress for everybody that this is not a secret experiment that you're doing on the iphone right now. we are talking about patients, controlled studies, as is being done carefully. what it does if it gives you a sense of the power of the data available on her cell phone and increasingly sophisticated things that people can do that. the second example is about sensors. a company called greenacres, which takes tiny wireless

sensors, very inexpensive sensors and packages them in little stickers that you can slap on everyday household objects and start to do things like how competitions and your family about who is doing a better job brushing your teeth. this is just an example of the creative and very inexpensive things you can do were going to be increasingly ubiquitous and powerful sensors. we are seeing this play out initially in the fitness tracking industry, some examples that i have up there are ones that will track activity on the calories you burn, it will put it on a wristband and ignited and tell you how well the slot. there is the wifi scale. you step on it and you automatically log your weight and god for bid you can tweet it is well that way.

contractor runs, strapped onto your arm, go for a job jog and it will figure out where you went and how far and how fast you get it and you can also put on the wireless heart monitor while you're doing it. the next time you go see your doctor and she asked if you're getting any exercise, you can say more and i am trying and you can pull out shards of everywhere you have run, how far you have gone, how often you do it and how fast you run, for extra credit, how fast your heartbeats when you run that far that fast. don't try this at home. i don't recommend it actually they do this right now. they don't need to know all the details but the key point is what used to be a very vague and precise answer cannot be answered with great precision. it is not just limited to

fitness could you are increasingly seeing trackers that will rate your mood and sleep and indicators and drivers of health. the big question in all of this is just having access to all that data really modern? and that is the question that we have been trying to answer and project helped design, which is, as i mentioned, a program of the pioneer portfolio. it is run under the university of wisconsin. in that program, we found that five teams to work with real patients and clinicians to collect what we call observations of daily living. we think of them as the measurement, the data associated with your day-to-day experience of health. data on mood and sleep and diet and exercise, stress levels, the meds you actually take as opposed to those you are prescribed.

and so forth. and in these studies, what we have done, we have created applications and services for patients to be able to capture and store these. we don't actually provide feedback to the data within them. and this is something we will talk more about today, the tricky part about integrating that into clinical care. bringing that into the doctors office and so on. so we have five teams and working with very different populations and conditions. low and income, adult populations with asthma and typically, mental health challenges like anxiety or depression as well. analogy m.d., is a project for people with crohn's disease. the wifi scale for weight and then a special application on

ipad recording thing things like food and stress and energy level and actually just a journal to record subjective thoughts about how you're feeling. and then what they would do, the data would get charted and then they would bring it into the doctors office and discuss them with their doctors and you can see how the condition is developing and everything is going on. and then a project on seniors with risk of cognitive decline. they looked at three general daily routine tasks, making phone calls, taking medications and making coffee. and they put sensors on them and then they look for patterns that show that people are starting to have a little bit more confusion about completing the tasks. making more mistakes, they are taking longer to do them. seaview could actually notice the onset of progression or target of decline.

and an application for babies that have been in the neonatal care unit, and the parents can track their progress about the baby. things like the number of diaper changes, weight, also looking at things like are the parents doing bonding activities with children. also, the parents general well-being and what their motives, day-to-day. anyone who has experienced parenthood for the very first weeks or so, they know that it's an intense time and you have to watch your own health during that. the last one is in touch, which work with young women, teenagers and young adults who are obese and also suffering from depression. and they had a mobile lab where they could report information about their diet and activities. social activities and also their mood as well. and then they would review the data with health coaches who would give them feedback on how to do it.

i want to emphasize a couple of things about the project. first of all, we are talking about patients with serious health challenges. these are all tough diseases and as you see in a number of examples, they have conditions as well. it's not just asthma, asthma and depression, for example. patients that are very high cost of the system. these are also not typically affluent tech savvy patients. a lot of these folks are from low-income backgrounds and had very little familiarity with the technology they were using the project. i also want to emphasize the projects are just wrapping up the valuations have not been completed. we don't have very hard, clear findings of that. but i can share some preliminary observations we have seen in the experiences of those projects.

first is the question of what people actually do this? with people track their mood or diet using mobile devices or other ways. and the answer is by and large, yes. certainly not everybody and not everyone who did would check it all the time, but we saw a substantial number of people who did put in enough effort that we could gain value from it. there are examples of where the direct feedback of the patients made a difference. showing somebody day-to-day medication adherence, when they have been taking their pills, if they have been taking their pills, it brought some real insight to the patient. i thought i was doing well, but i look at this and i'm not. i need to adjust my routine a little bit and be well. there are cases in the intouch project where people who are checking their diet regularly actually started to make real

changes as well. in some cases, they lost quite a lot of weight. there are definite examples of information making a difference in treatment. steve is going to talk about a couple of examples from the brief easy project. there is one from the chronology that i wanted to share because i thought it provided a great example. this is a quote from a patient. he writes is there any way to extend the study. and he says i am finding this very useful. i have used this data with other doctors outside of the study, and as a result of sharing this data, i have changed the medications i was on. as a result of this change from high, my quality of life has gone way up to my weight has gone from 112 to 119 pounds. that is a good thing in this case. and i am not vomiting daily. this is a really good example of how little bit of information dated a novel and make a difference in treatment that the

change in treatment can make a difference in a person's health. it also represents a real challenge to the system. i think we all know that doctors are extremely busy and the current mode of practice does not make it easy to add in the extra time to review this data. the second thing is that the electronic health records -- one way is to record patient blood pressure. it's a whole another thing to figure out how to read mood, which there are very few standards are now. so to summarize i want to say that technology is creating a new opportunity to practice medicine somewhat differently. the small studies that we have done, they are showing that there is real promise and not

necessarily with tech savvy patients. as often the case, the policy environment -- the context around which they play out, it was not developed with these innovations in mind. we are going to have to take a look at that and i know that joy will address that and deven mcgraw will address it as well. thank you very much, steve. indeed, beating a practicing medicine, we now turn to doctor stephen rothemich, who is a professor at virginia commonwealth university. he is the codirector of the brief easy project, which is run with the help of the folks at vcu. using advanced technology for caring for patients with asthma. he also codirect practice-based research network and we are happy to have you with us today.

>> thank you. >> good afternoon. i am a lead clinical investigator on this project and i want to be sure to acknowledge the doctor in charge of this, she works at rti and a leading researcher in user centered design, which is an important part of developing this application. i also want to reinforce stephen downs said about the variety of the different byproducts. i encourage you to look at those. currently, we have more clinical integration than some of the projects. a lot less with the physical sensors and electronic passive acquisition of data. most did require it if you should take steps towards that. going on to the next slide here. very good. i'm going to talk first about

the application and then go back to the patients are we saw. so the patients in the project under their data through a brief easy out on their android smartphone. if you look at the one on the left, you enter your daily data. this is the place where the subject would go on a daily basis to answer a series of questions for the ovl's that we negotiated between patients and clinicians as being the ones in this study. those include medications if they were on him, why they had music, the peak flow readings, which is a measure of how well they are able to move. exposure to asthma triggers, mood, anxiety, sleep, exercise, tobacco use if they smoked. and whether asthma limited their

activities and what symptoms they have had. you will see in terms of users the user's experience, they were checkboxes, radio buttons, places with numbers and this is the basic process that they would do. the next couple of icons on the left screen those were optional ones that subjects could use during the day that they wanted to report additional ovl is about. the last one says dashboard. i'm going to talk about the clinician dashboard in a minute. the same data was viewable by the patient by intermittent content information that they entered in their odl's. >> this is a screenshot of a collision sport. this is what the clinicians use in the practices, it was web-based, they use this on the

laptops or desktops that they used. i want to point out a couple things to you because it's kind of hard to read. at the top of the screen, you'll notice a green, yellow, and red bar across the top. those are where we display the peak flow readings. we used the national asthma guidelines, numbers of 80% or better of your predicted sloping green. that is correct. it is where it should be. if it is less than 50% of what should be, but that is red -- the danger zone. obviously, yellow is in the middle. below that you'll see a lot of green and red dots. what we did is the other odl's, we decided to display them on the dashboard, rest, smoking,

asthma symptoms, we tried to make this as easy as possible for the clinicians. green is good and red is bad. green is a desired state. for example if you are out of control, you did use it, you were not exposed to triggers and red is like you did have symptoms or you you smoke or you have to used your hair inhaler today. that is what the commission has looked at. now i'm going to talk about the setting in the patients. before we did the six-month evaluation, there is a whole series of steps with user centered design process in terms of having focus groups, patients and clinicians, improving what we had done, go back to them, seeing if we can get it right before we actually fielded it.

we picked patients with moderate to severe asthma. we picked them because there's not much going on with mild symptoms. we also do this with two practices, predominantly black women, 24 to 30, low income, 18 of the 30 have low educational attainment as well. why that group? this is a group that has more challenges. if we can get folks -- those we might expect would have a harder time doing this, do it successfully than probably anybody can. they entered their odl data at a time of their choice. each of them was given a smartphone with six months of phone and data service during this evaluation. i think two of the subjects have

a smart phone already and not all of them, i don't think, have cell phones. those are the patients that we have worked with. to inner-city practices in richmond, virginia, same electronic medical records. i worked in one of those. seven nurses, we did a study which is typically how we practice. once a week, with the nurses would do, they had a protocol that they would look at the dashboard david assured her minute ago. and they will determine whether there was actionable information that needed to be escalated to the position to address. and we focused principally on peak flow, whether or not they were using the control of medicine, whether they have used the rescue medicine and whether or not they were having symptoms. if clinicians know what to do with that -- he looked at lex sleep, but we were not clear what we should do those things.

the practices were paid $500 per subject to monitor that patient. the way an insurance company would probably call that disease management, or we now talk about medical copayments, perhaps. >> okay, so this first example, i have to i'm going to show you this is a young healthy person whose biggest problem is that they smoke with asthma. this patient, i have actually collapsed the information she can see that pattern in the peak flow. makes it hard to read that green dots at the bottom, but surely the peak flow here. you notice that the subject at the beginning of the study was red and yellow much of the time. the nurse message the position about the continued pattern of

this. right before it starts to go up into yellow, the clinician who have not been successful getting the patient to come in for an office with a decided i'm going to start this person on a controlled medicine. obviously, he needs one. that was called income in the nurse talked to the patient about how to use it. they started using it, and about a week later, up into the yellow to green zone, staying there the rest of the time. not just these numbers, but also if you look at the second row of rescue medications in the last row of asthma symptoms at the bottom, you'll see that there is less use with asthma symptoms in the second three months of the study after they got on these medicines that were controlled. if you want to control what medicine at the beginning, you

actually didn't get asked that question. that road is not relevant for this object. that was exciting. the green dot that is out there, there was a typo or somebody collecting peak flow. it makes it look much higher than it is. i think it's a typo. the second and i want to talk about is the more challenges patient for this services is subject in the early 50s. hypertension, very common. she has lupus as well. this is showing about two months worth of data as you can see the stars and exes a little bit better. when we started collecting data on the station, all of these numbers were actually in the red zone. the reason they were better than not is the primary care physician caring for this patient, obviously, the

predicted peak flow, the formula-based one, was not accurate for this individual. we use the readings to kind of reset the flow. if you look at those 300, it's not really that number. what happened with the subject is the nurse observed below are peak flows in the patterns of mass, they have to use the rescue medicine every day, having asthma systems just about every day. the commission in this case, a much fancier tests than the peak flow that the patient said. what they found was that this was not reversible. asthma is supposed to be a reversible lung disease. the diagnosis of different lung condition, copd, it was entertained by this they decided

that it was asthma, just beer, refractory asthma and this was a candidate for monthly immunotherapy drugs that we don't administer at my practice. only a specialty-based care type of situation. this patient had actually not started as the very beginning. so very quickly since i'm running over the time, we did separate patient and clinician forms at the end of the study. and these are just a few things that i want to mention that we have learned at this point. patients found it easy to use. they reportedly enjoyed the odl's, they understood the asthma and triggers better. they were encouraged by this. frankly, it surprised me how well they could do this. the clinicians were not overwhelmed. that was good news, because we were a little bit worried about how that would go. they reported it that it did

indeed provide clinically useful information. education opportunities from a couple of patients who had their controlling meds and rescue medications commonly misunderstood how to use them, and that was corrected by the nurses over the phone. we had patients who had that there be escalated, sometimes between or without visits or abbasids, and we had come as i mentioned, diagnosis change. we had some were diagnosed with copd and one changed back to disappear refractory asthma. severe refractory asthma. and i am done. >> thank you very much. you have heard a couple of interesting presentations about how some of these technologies work in the real world. now we are going to turn to a couple folks who know a lot about the policy implications of

starting to use these technologies. we are going to start with deven mcgraw who is the director of the health privacy project at the center for democracy and technology where she works on ensuring individual privacy is electronic health information is shared she is also on health information technology policy committee was set up by the 2009 stimulus law. we are very pleased to have deven mcgraw with us this afternoon. >> thank you so much. i do a lot of work on policy issues in privacy and security. with respect to project health designs, i took on all of us really a bit for me. i teamed up with a lot form for the part of the legal and regulatory assurance team. to assist them and then navigate

the laws that would apply to the project that they were doing and providing them with a path forward. also to try to service some of the bigger policy implications that really a road out of the projects, collectively as well as individually. it is really exciting to have an opportunity to think about these issues in a kind of on the ground implementation way dealing with rubber meeting the road. we started by providing them with legal memos and thankfully my colleagues helped and handle this aspect of it. just put down, nitty-gritty, you have five guarantees in three different states. all of them are subject to the health insurance portability and accountability act rules around privacy and security. how does it apply to these

projects? welcome in addition to concerns about basic compliance with the law, each of the guarantees early on identified three buckets of concerns that they had some from a policy standpoint. one being the security for a mobile tool that the patients would be using into the project. we won't go to down in the weeds about security and mobile devices, but many say that these devices -- sometimes you can buy programs it can make your phone more secure. most people don't figure out how to do that. there were also some concerns raised about potential professional malpractice liability by the clinicians for

the potential to be receiving all of the data from the patients. what they didn't see something that was in the data and what they mr.? and what would that mean for them from a professional liability standpoint? as i will explain in a moment, diplomatic policy regime does not apply in all contexts. covers some data some of the time, but not all of the time. given that some of the data was going to be collected and stored in environments that were not going to be covered by a to be covered by headbutt, would that mean for the patient's? these were all really concerns that were brought up by the project sponsors. the really on behalf of the people that they were going to be acting to participate with in these projects. an overarching theme is that these arrangements are very unique and innovative. but they can be done and be legal and pocket content policy

concerns that service from the beginning. certainly from a legal standpoint, all could be done in compliance with the law. as i mentioned earlier, it is handled by the health care providers. so that data would be covered by the privacy and security law. on the patients were participating in the projects were entering metadata into their mobile devices, it was actually not covered. you had a regime we've had a certain set of rules that would apply to part of the projects, like maybe half of the projects are 40% of the projects. but the other part would not necessarily be covered by clear or how you feel about them,

western clear rules. rules arbasically, you know, if you pick up and start using a mobile device and entering data, you need to read the privacy policy to determine what the data sharing rules are that are going to apply to that data. in those promises can be enforced by the federal trade commission. but that's not the same as having a comprehensive set of rules about how that data can and cannot be used. there may be state laws, but again, we had guarantees. three of them in california in two and two other. sometimes the state laws, it can be a different application in terms of who they apply to. there is not typically a regime where all health data, is subject to some sort of production. each parent who is only responsible for complying with its own state law. we did have a project that involved minors very the intouch

project. the adolescents and teens struggling with weight issues and sometimes mental health issues, the state law often provides a big role in determining who can access data and placing protections around that data. in the case of that particular project, which took place in california, there were strong rights for minors to be able to direct and control their own data once in the health care system. those rules are not as applicable outside. one thing that was incredibly helpful in each of these projects is that all of the institutions involved treated this as a research project, which meant that it was subject to internal review and all the participants were at a consensus of the project, they understood how the data would be used in collected, an environment that isn't always present in the private sector when you talk about consumers using

off-the-shelf products. it really created moments of transparency and education for the patients. for those we don't always have. when we are talking about purchasing and using the tools in a commercial base. as these projects are wrapping up, we are trying to take the experience of the project health design guarantees and managing these critical policies and turn them into papers that can help inform others who might be engaged in similar projects. the first paper that we did was really about mobile device security, and it has actually been published in the journal of health information management in the summer issue. there is a copy of it in your packet and it is available online. many security devices and

recommendations that you might mandate the use in a provider contract, when you're talking about patients using these tools in making sure that they are able to utilize the minute in a comfortable way, you might have a different equation. if you say that you have an ability to protect your device. but you can't make them password-protected device. the extent to which they use password protection is up to them. another example is the guarantee, it put in the capability of being able to remotely like the device of data that were lost or stolen. the patient doesn't feel -- it gives them a sense of security. it did happen in one of the projects, a device was lost and they were able to remotely wipe the data off the device so that

couldn't be accessed by persons who are not authorized to see it. the paper includes a number of best practices. again, we look to the security but for guidance, but it is really where the security rule did not apply and it provides a set of best practices. a second paper that we have drafted and we are seeking to have published is how did the professional liability concerns diminish. essentially there are two overarching things. one is this idea of a never ending potential stream of data from the standpoint of the positions, they were -- there was a negotiation about what they would be collected, who's going to look at it, how often. not in any project of the data automatically just did dump into

the electronic health record without positions being made very careful planning on their part. as a result, there really was a level of comfort by the clinician for participating in all the projects, as well as the patients about the expectations, which are very clear, and people stuck to them. we perceive that to be very important. there is not a lot of case law on this. in terms of looking at ways to manage concerns like providers, it is absolutely doable but you have to be willing to put the time and are having this discussion and having those understandings be very clear among the providers and patients. the last paper that we are really looking at is the issue of we do have privacy protection for one part of this equation.

and we don't have it for the other part of the equation. we are trying to encourage patients to use these in a more robust way. you have those opportunities to talk to people about what this means for them and what the potential risks are, what the potential benefits are, then they can make decisions accordingly. what does that mean for policy going forward? that is the people that are trying to write -- not as we speak right now, but they were working on it. that's all i have to say about that. i'm certainly going to be here to answer questions about how we dealt with those issues in these projects. thank you. >> thank you. thank you so much. finally, we are turning to joy pritts, who is the original chief privacy officer in the office of the hhs, she has been

at that post for 2.5 years. we asked her to read it, tell us a bit not only that privacy concerns, but also patient generated data in general. thank you for being with us, particularly on the short notice that you got to be part of the event. >> thank you for having us. my office, before i start, i want to explain to you. it is the office of the national coordinator for health information technology. the office was formally created in a high-tech area. it is, which is part of economic recovery act -- our office is designed to incentivize people and adopt health information technology and health

information exchange. so it is a somewhat unique office in the department. because it really is totally focused on health. hhs as a whole has a real interest in putting the patient at the center. anyone who has read the affordable care act knows that hhs and this congress -- the congress, when they drafted the affordable care act, with the patient in the center. we are willing to follow the patients, not just how isolated instances of care. and it's essential that the patient be a partner in their care. they are the ones who have a lot of the information, as everybody has said, about what everyday life is like. and how that impacts their care. most care, as you all know,

doesn't take place within a clinical setting. it actually takes place outside of the clinic. it is really important that we know what is happening outside of that environment. people who are engaged demonstrate better health outcomes. i think all of these projects that are being run by project health design, demonstrate that. we are challenged to get people engaged in their health care. people have a lot of other things on their plates to do. they also face a lot of, i would say, cultural challenges in becoming more involved in their health care. because this is one of the areas where the culture is changing, even as we speak. but when people aren't engaged, they do have -- they can have better health outcomes. as janet mentioned earlier, patients now, they expect to be

engaged through i.t. and everything that they do, including in their house. ..

shown an interest in getting patients access to more of their own health information by releasing notice of proposed rulemaking almost a little bit over a year ago now. almost a year ago now. with the privacy rules. for those of you not familiar, when individuals are given access to their health information there is of little carve out for a commission which was held by clinical laboratories who are subject to the clinical laboratories improvement act. to make a long story short notice proposed rulemaking which

is a joint rule because there was a piece of hipaa that had to be changed in order to make this happen. it would lease and the rights of patients to directly access in lab test results. and it is designed to empower patients to be more informed partners with their health care providers. and as was mentioned earlier in more detail than i will go into, there is also -- there are also provisions in the npr him further meaningful use stage to that also focused on making information more accessible to patients. o emc has taken a focus on this area and has created an office of consumer engagement which is currently being run by the acting director. many of you're familiar.

this demonstrates how committed they are to not only making sure that providers are meaningful using health of permission but also that patients can also do the same thing. the consumer and business strategy is based on what we fondly referred to as the three a's, access, action, and attitude. and it is very much kind of oriented toward the patients meaningful use, they should have access to their own health information, that they should be able to easily take action with that affirmation in a meaningful way and that some of these attitudes that have been ingrained in some areas of health care for a while, that patients are something that health care happens to instead of patients engage in. it needs to change. and we are working on all three of these three days in many projects.

in particular, 0nc has a number of patient generated data initiatives. one of these is up paper, of white paper which was commissioned from r t i, and it was released in april of this year. this discusses the technical operation illegal cultural and education issues that surround passion generated data because, as was mentioned earlier, this is an area that is a little bit different than the way we have thought about health information in the past as being something that is just generated in a pinnacle context. the policy committee which was rated under high-tech also had a hearing on patient generated data in june of this very reason your. this hearing material is also available on our website for those of you who have more interest in it. there is also a study on patient access to their health

information which looks at patients getting their access to information, reviewing it, and giving feedback to their providers, and it is exploring how that patients and providers are able to engage with this and whether some of the challenges which people thought would occur with patience generated data have occurred in this system, similar to some of the questions that relate -- were raised. this project is being conducted by the guys in there. the anticipated date it release of this study is the first quarter of 2013. and as was raised earlier, these patients generated data it does raise any number of legal issues

and in particular privacy and security issues. as you all know, we in this country regulate in the very sector specific weight. we have some rules that apply to this little piece here and rules that apply to this piece here. and a lot of people, particularly consumers, do think that hipaa protect all of their health information which is not the case. as dagen mention that, it does not apply to individuals who are entering their own information. a system such as ones that have been described. we recognize this. as a matter of fact, the administration has recognized that there are a number of ways in which people interact on the internet. the privacy protection probably does need to be heightened. and so there is a white house initiative on internet privacy.

it would actually provide what i want to refer to as kind of a safety net protection that would cover some information that is exchanged on the internet when it is not covered by hipaa or other federal laws. in addition to these large policy issues, we have done a lot of work in health and privacy and security in my office and particularly in the privacy office, office of the chief privacy officer. one of the things that we looked at was the security and mobile device that was mainly down from a provider perspective, but we looked at it from as it came out of the box. it is very interesting to look at. there is just a sea of red, even some devices where you could not set the password if you wanted to. in addition to that, we are conducting a focus group research which can not of that

text for health recommendation. we look into this issue. trade-offs that they were willing to make. the national strategy for trusting identities in cyberspace, which is another acronym which addresses the issue, one of the issues that janet raised when she did her opening about proving, identity proofing patients and authenticating them when they are working, submitting information on the internet. and those are some of the main things that we are focusing on. we do have this list of web sites that you can go to for more information on the work that we're doing in this area. >> terrific. thank you so much. we are now at the opening up of

the conversations states in this program. there are microphones that you can use to go to and verbalize your question. as i mentioned, there are green cards in your package that you can read your question on if you will hold that card up. somebody on our staff will pocket from your fingers and bring it forward. and to get us started, janet, you have been scribbling questions. the presentations have gone ahead. why don't you get us started. >> thank you. i would like to direct my first question to dr. ross match. first of all, thank you for sharing your experiences on the grounds with us. it was terrific to hear about all of the positive outcomes that you experienced as a result of using these technologies. so let's just say, if we were to look at scaling this across the country, you know, improving

these types of interactions among conditions in patients, which is very exciting, what action, either policy or otherwise, do you believe need to be taken to assist, particularly your fellow conditions? >> well, this audience is probably more policy expert than i am, but one of the things that i think we saw was, even with 30 patients and to practices, this was a sizable amount of work, additional work, new work that there were taking on to do this. and so i think one of our policy implications would be that with any work that gets done, at the end of the day someone has to pay for that time to get it done. so whatever the mechanism of payment might be, perhaps it is something that is directly reimbursable, perhaps it is something that is a potential savings to the organization,

accountable care organization are something like that. i don't know what the exact solution is, but i do want to a knowledge is a fair amount of work. from the practices perspective, i think that we would not have wanted or found useful to do this with every patient in our practice who have asthma. so we are focusing in on the ones that there was more likely had a benefit. and we did see them for six months, the commissions and patience both felt this was doable and useful. i don't know that either was necessarily going to say that two years later. so one of the things that i think we need to think about, there are probably certain times where certain patients would benefit from looking at this affirmation this intensely. the patients who are having repeated visits to the are. we can't get their asthma controlled, and for a time that would need to be looked at very

closely. and then obviously the practices have to figure out how to do this in workflow. >> thank you. >> we have a number of people lined up at the microphones. i would ask you to identify yourself and keep your questions as brief as you possibly can so that we can get through everybody's inquiries. i don't know who was first. we will start on my right, your left. based on not utilizing health

care as much as they could be. any failure, resistance to more if it is to be changed, maybe your insurance provided does not want you to know that you get the free pair of glasses or you get this free or whenever it is. on the other side is an opportunity if you think this will affect the copay structure. for example, if you get an alert saying, hey, get your free hiv test. it's that time of year. get your free preventative visit. so what do you see happening as far as civilization goes to iraq >> steve, everybody seems to be turning to you. >> great questions. i mean, i think the utilization is really probably going to depend very much on the cases of who is using it under what circumstances. as steve c-span, in some ways that think what he is arguing is, you need to find the case, elements of business cases around under what circumstances it would make sense to do an intensive look as someone's

affirmation because you think that's going to make them healthier in the long run. reduce utilization. at that point the model, like accountable care organizations where actually, realizing those savings makes a difference and is part of the business model. you know, and to be honest, we have not engaged deeply with the insurance industry on this other than to have an adviser from the industry, and these projects were sort of done of book in that sense. the copay thing is really interesting because this sort of model of practicing care gets you a little bit away from the notion that health care is delivered in doses where you show up to an office and receive treatment. this is sort of saying, it is much more a continuous relationships, and the idea of a copay starts to make less sense. maybe the copay, if you really want to come in and use the

office and talk to them, that is a copay. if you want in this direction, maybe there is no copay and all. i don't know if others have dealt with that. >> go ahead. >> yes. hi. i represent that smart technologies, which is a vendor that provides electronic health records of providers. this is a question to joy pritts. we have become concerned about reports, confirmed reports state health affirmation exchanges are not accepting mental health and addiction electronic health records because of conflicting interpretations of state and federal patient company chilly concerns, particularly related to open addiction records. we know, joy that you are working with the substance abuse and mental health services

administration on these issues. i have two questions for you. number one, if you could just tell the audience a bit about how the linseed works with samhsa, special currency value records. and secondly, anything you can say about this pressing hip matter would be very happy to of helpful to gasol. outage response exceeded. >> in response to your first question, we work very closely with samhsa. for those of you are not familiar with those rules, there is a federal -- this set of federal regulations that apply directly to substance abuse and mental health -- well, substance abuse -- substance and out all abuse treatment facilities that receive federal support which is very broadly defined. those rules are more stringent

than the hipaa privacy rule, and they require an individual expressed permission to share their information, even for treatment purposes. the purpose behind several, when it was a reason it was to make sure the people who have these conditions would come in and get treatment without fear of being arrested, frankly. and to our knowledge that last piece has not changed over the years. there is still danger, potential rest of this information falling into the wrong hands. so the challenge that has evolved is that the rules -- rules were written very much at a time in a paper world. so although the policy may not have changed, the implementation of that policy into an electronic environment has proven to be somewhat challenging.

we were -- as i was saying, we work very closely with samhsa. we were working with them on the -- trying to find some solutions to this. we have heard, as you have stated, anecdotally that some of the health of permission exchange organizations that are forming are hesitant to accept the information that is generated from these substance-abuse and mental-health facilities because it is one of those areas where the protection actually follows the data. generated in what we call a 42cfr parts to facility. then, when it is exchanged with -- what goes into the patient's consent for it to be shared, the recipient gets it. we disclose that affirmation.

so we are working on a number of different fronts on how tough tackle this issue. we recognize, and the administration recognizes how important it is to have these substance abuse and mental health really integrated into primary care. one of the things that we have been doing is working on standard developments for meditated tagging misinformation that they might provide, help provide a technological solution to this challenge. and, as you know because you mentioned is, that the -- samhsa has been working with a number of states to try to find ways that they can not necessarily harmonize, go back and redraft all kinds of laws, but look at the interpretation of things that exist in their states to

see if at least they can come up with some common solutions of approaches. one of the keys here that people need to understand is that the pre-emption, the federal pre-emption, state law, which is equal to or more stringent than the privacy protections and hipaa remain in place. in itself it is not just those two areas that you mentioned. in any state law where there is -- where state law mandates that an individual can send must be obtained for the specific purpose, it is presenting a challenge. and i think it is very important to point out that it is not just this one little area. it is a much wider issue. >> while we have you speaking about the reach of hipaa there is a question on a card that i

think we can dispose of fairly quickly. and the question i would like to know whether the health and history in formation they enter into a terminal in their doctor's office is covered by hipaa. >> provided that your health care provider is covered by hipaa, yes, it should be. >> okay. yes. back here. >> john green with the national association of health underwriters. i wanted to know if the panel share the concern that i have relative to a provision of pdufa that would give oversight of approving applications to the fda, and that whole process which is very timely and costly when the shelf life of an apple is short and a lot of these people who develop them are working out of their ross, for instance. coming up, you have to make it worthwhile. i wonder if you had any concerns

relative to this oversight about , is the smart phone no medical device that has to be approved by the fda? we would still be waiting for angry birds if it had to go through the fda. >> whoever answers that, would you take a moment to explain from some of los what pdufa is? is it a town in illinois? >> i think that is paducah. >> prescription drug user fee amendment. this whole issue was included. the fda now says they would like to have a peek at applications and whether or not it is a medical device. the texas side how long it takes to get things approved when they

don't have the staff and management now said to doe work they already have and want to take this on. >> did you want to take that one? i'm happy to talk about it. >> estimate is the case that the food and drug administration is looking at the extent to which it is congressionally authorized authority to regulate something that is a medical device extending to certain things that are on your phone like an application. i doubt it's going to extend to angry birds. those of us who don't play it think maybe it should. >> in the studies that show that it improves of a decrease is. >> no. but so, i think it is a difficult line to draw because on the one hand there are two guys in a garage creating an application that a health care

provider is going to use to make a decision about the clinically where it actually operates a lot like a medical device. here's what the person's blood pressure is. here is what it is after they do a certain thing. i want somebody to look at it and make sure that it actually works as it is being -- as it is being presented to the world and being sold to the world. on the other hand, if you have got a device helping you track your fitness level where you may be using it in terms of deciding whether you're going to run faster than next day and maybe if it is off by a tenth of a mile or to no one is going to die. that is not necessarily need to get through full device regulation procedure. i think that what the fda is trying to do is draw a line. they're attempting to do this. what is a mobile medical app? what is a wellness app?

through the types of information more on the clinical medical side, generated and collected by an apple and used to make a clinical decision verses information that is used to help the llamas. that is not an easy line to draw as steve made, the point that affirmation that does not look like after intermission in one context is relevant to your health and other context. so, you know, from somebody who represents consumers in some of these discussions, i don't know that i want to say fda go away to some of these apps that, in fact, are designed to be used to make medically relevant decisions where if the device -- maybe there is a test, you know, that piece of balsa permission coming out of this device resulted in somebody getting hurt? then i do want somebody looking, some sort of standard be applied. having said that to what does

that look like? under what conditions? i don't think it is at all clear to the extent that, you know, regulation when it is not done appropriately and surgically correctly can be an innovation killer. that is problem number two. i don't think it is as easy as saying at should not be regulated at all. some of them actually are used for clinical decision making. >> i agree. if you go back to the example i gave earlier of a company that would set the date on your cell phone and establishes a behavioral signature and then is able to look for changes against that, if the output of that was to say we have noticed a change in your behavior and it appears he may be sliding back into depression, you should double your dose of prozac immediately in order to save that of, you kind of what what that regulated. if what they're doing is to say, we have noticed a change in your behavior where, you know, you may be concerned about this. you might want to discuss this with a doctor to see figure out

appropriate course of action. i mean, those are sort of easy last drop, i think, when you hear in the developer community, the most important thing is however they are drawn, they are drawn and clear because i think that is the hard thing. if you are the two people in the garage trying to build the company and you have something and it is really unclear whether or not you're going to need fda approval, that is really hard -- those are hard circumstances to work under. >> what you just said sounds like whenever the line is might be drawn less on the actual app than on the use to which the information is put. >> it depends on, you know, the apple and the service. i think that is right. not so much about the data collected, maybe even less about the analysis of the data, but more about any recommendations for action about that.

and actually, that brings up another point. the focus groups research that was done with the chronology after patients had a chance to use that, they talked about being able to see connections among different aspects of their health. for example, patients were saying, you know, when they looked at activity level and sleep and noticed that more activity in more sleep had a real effect on their energy level, but actually, being increased had an affect on decreasing their pain level. that is an important insight that you can get from an application, algorithms. and you can make changes in your behavior, you know, that can help you take advantage of that. i don't think anything in there is necessarily allowing us to rise to a level of medical treatment or providing medical advice. at the same time it's important insight that you can get from the debt. >> i just want to be clear that i did not mean to suggest that there should be no oversight. i think oversight is good, but

it has to be reasonable and timely. it has to make sense financially . >> yes. we are at this microphone. >> international journal of hygiene and environmental health. i hope, can you imagine a scenario where it is required or mandatory to provide mobile data in order to be eligible for a certain health care plan and how we could prevent that. >> while. >> interesting question. >> i will take the first crack at that. the technology infrastructure to make that possible is obviously there. that could happen. that is where policy comes in, and that is why it is so important when you have technology in the applications of technology emerging